Missing multiple clinic appointments soon after starting HIV
therapy is associated with poor immunological and virological responses, and an
increased risk of death, South African investigators report in the Journal of the International AIDS Society.
They found that patients who failed to attend their clinic
on two or more occasions in the six months after starting treatment had
generally poorer outcomes than those who turned up for all their appointments.
“Missing visits early is a marker for those who will have
poorer outcomes even if returning to care,” comment the investigators.
At the end of 2008, over five million people in resource-limited
settings were being treated with anti-HIV drugs.
“Initiating this many patients onto care in such a short
time is a remarkable achievement, but not without its challenges,” write the
researchers. Mortality and loss-to-follow-up rates are high in many countries,
and keeping patients in care can be difficult.
Investigators at the Themba Lethu Clinic in Johannesburg
wanted to see how many of their patients missed appointments in the six months
after starting antiretroviral therapy. Their patients’ medical records were
monitored to see if missing appointments was associated with immunologic and
virologic outcomes after six months. The relationship between clinic attendance
and mortality or loss to follow-up over twelve months was also investigated.
The study was retrospective and included 4476 individuals
who started therapy between April 2004 and August 2008. All were aged over 18
and were starting HIV treatment for the first time. Their median baseline CD4
cell count was just 76 cells/mm3, 63% were women, and 89% were
treated with fixed-dose d4T/3TC/efavirenz.
Appointments to collect antiretroviral drugs were scheduled
at monthly intervals, and patients were also supposed to attend three medical
Overall, 65% of patients attended all their appointment, 26%
missed one appointment, 7% missed two, and 2% failed to attend on three or more
“We identified strong independent predictors of missing a
medical or ARV visit,” note the investigators. These included being a man
(medical visits, adjusted risk ratio [ARR] = 1.16; 95% CI, 1.05 to 1.28; ARV pick up, ARR = 1.15; 95% CI, 1.15 to 1.28)
and treatment with nevirapine (medical visits, ARR = 1.18; 95% CI, 1.10 to 1.40).
Missing three or more visits was significantly associated
with a poorer CD4 cell response (increase below 50 cells/mm3) after
six months (RR = 2.3; 95% CI, 1.4 to 3.8).
In addition patients who missed two or three or more visits
were significantly less likely to have a viral load below 400 copies/ml at this
Patients who missed two medical appointments doubled their
risk of death (ARR = 2.06; 95% CI, 1.00 to 2.06), and missing three or more
antiretroviral pick-ups was associated with an eight-fold increase in the risk
of mortality (ARR = 8.15; 95% CI, 1.97-33.7).
The researchers suggest that failure to collect therapy
could indicate poor treatment adherence. They also suggest missing medical
appointments meant that opportunistic infections and other serious health
problems were not being diagnosed.
Missing early appointments also increased the risk of being
lost to follow-up significantly.
“Documenting the amount of missed visits early on treatment
is crucial because of its potential implications for poorer treatment
outcomes,” argue the authors. They note, “in our study, more than 35% of
patients…failed to attend at least one clinic visit in the first six months of
They conclude “our findings suggest that targeting those who
miss visits early on in treatment could have benefits in terms of longer term
mortality reductions. Future studies need to focus on identifying the barriers
to adhering to a visit schedule s that interventions and support services can
be directed to those at risk.”